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10 tips for TJC readiness; Letter from Wm. Bradshaw, MD

Mar 21, 2014


Baptist Health System will be participating in a triennial accreditation survey with The Joint Commission (TJC) in 2014. This survey provides us with an assessment of the quality and safe patient care we deliver to our patients as a healthcare system. Our goal is to maintain our recognition as a TJC accredited healthcare organization.

Our TJC survey window is open, which means TJC can arrive at any time for our unannounced survey. A TJC Awareness Campaign for the Medical Staff began this month with an overview of the Medical Staff related opportunities for improvement being shared at each of our Medical Executive Committee meetings. We will be communicating these opportunities for improvement to our medical staff at large through a variety of communication channels such as our weekly physician newsletter, medical staff committee meetings, message board updates and posters.

We need the commitment of every Medical Staff member to achieve TJC accreditation. Your role as a medical staff member is to actively participate in ensuring ongoing compliance by:

1) Conducting Timely & Complete Assessments such as:

  • History & Physicals (H&P's),
  • Airway Assessments (Mallampati Classification)
  • Post-Delivery Notes(to include completion ONLY after the procedure) , and
  • Immediate Post-Procedure Notes (to include completion ONLY after the procedure)

2) Updating H&P's by using the 'BHS H&P Update Note form' or the 'BHS Update Stamp' to ensure there is documentation that supports examining the patient. 

3) Signing, Dating, & Timing ALL entries in the Medical Record.

4) Writing Complete Medication Orders (to include medication name, dose, route and frequency). 

5) Writing Complete and Timely Restraint Orders (to include the criteria for the restraint and the type of restraint).

6) NOT writing "resume" or "continue" medication orders or Do Not Use Abbreviations such as "U" and "QD." 

7) Utilizing Infection Control Practices such as:

  • Hand-hygiene,
  • Complying with isolation signage,
  • Not eating or drinking in patient care areas to include the nurse's stations,
  • Disinfecting equipment between use to include stethoscopes and
  • Wearing proper Surgical Attire 

8) Authenticating Telephone Orders within 48 hours & Restraint Telephone Orders within 24 hours. 

9) Participating in Safety Initiatives such as Time Out and Post-Procedure Verification. 

10) Watching for alerts regarding new and/or changing standards such as the NEW National Patient Safety Goal 2014 focused on Reducing the HARM associated with Clinical Alarms.  

You have my support as well as support from each of our Medical Staff Leaders. If you have any questions or need additional information please do not hesitate to contact me, your Chief of Staff or Chief Medical Officer. 

William H. Bradshaw, M.D., F.A.C.S.
President, Medical Staff 2013-2015

Baptist Health System